From disease to illness and back again

Perspektiven der forensischen Psychiatrie

Major lines of thought within the development of forensic psychiatry are discussed. The historical perspective will be helpful in creating a solid theoretical framework for the ongoing debate on the objectives and methods of forensic psychiatry as a scientific field and will support arguments against uncritical shortcomings and simplifications, so often met in recent years. Forensic psychiatry can only be understood properly in the context of general psychiatry, including its historical dimension. Significant neurobiological and neurophilosophical approaches to the mind-brain relationship in general and to the etiology of mental disorders in particular are outlined. Although to some psychiatrists they appear provoking or even threatening in a way, they offer the opportunity to rethink major conceptual issues within clinical and forensic psychiatry.

Listening to mothers: qualitative studies on motherhood and depression from Goa, India

There is little qualitative research on depression in motherhood from non-Western societies. The objective of the study described in this paper was to use qualitative methods to investigate the cultural validity of the construct of post-natal depression (PND) and its social and cultural contexts. The study was nested in a cohort of mothers recruited to study the risk factors and outcome of PND in Goa, India. In-depth interviews were carried out with 39 mothers (19 of whom were found to be suffering from PND as defined by a cut-off score on the Edinburgh PND scale) and their husbands purposively recruited from the cohort. An illness narrative was conducted with mothers who were categorized as suffering from PND and their husbands to elicit their explanatory models. The two groups (PND and non-PND) of mothers were comparable in terms of socio-demographic characteristics. PND mothers had lower levels of practical help and emotional support. The symptoms reported by PND mothers were similar to those recorded in studies with women in other cultures suggesting a universal clinical presentation of PND. Causal attributions for the experience of depression focused on economic difficulties and poor marital relationship. All mothers expressed the need for more practical help and support during the period after childbirth; husbands in both groups were often disengaged from baby care or supporting the mother. The study provides validity for the construct of PND in an Indian setting, but also shows that the emotional distress is interpreted from the context of social adversity, poor marital relationships and cultural attitudes towards gender rather than a biomedical psychiatric category. Contrary to the assumption that socio-cultural contexts associated with childbirth in non-Western societies protect mothers from depression, factors unique to the culture such as gender preference and the low involvement of husbands in child-care are major causes of stress to mothers.

Sudden infant death syndrome: a hypothesis

A study of the strikingly low incidence of sudden infant death syndrome in Eastern countries revealed significant differences in infant handling thought to have an etiological bearing; therefore this writer suggested that adoption of certain Eastern methods of nursing may reduce the incidence of sudden infant death syndrome. A dramatic fall in incidence has resulted from implementing one of the suggestions made by the writer in 1983, namely the abandonment of the prone position, after initial opposition. The present hypothesis sets out to give a scientific explanation for this fall, and is a unified hypothesis explaining certain puzzling and disparate features of sudden infant death syndrome such as the remarkable winter incidence, age incidence, and the occurrence of sudden infant death syndrome during sleep, and is based on a postulated disturbance in thermoregulatory function (a unique hypothermia). Recommendations are made for evolving a test for sudden infant death syndrome-proneness and a possible method of treatment of a fatality within a short time frame.

Anthropology and psychiatric epidemiology

Psychiatric epidemiologic research has been criticized by anthropologists for ignoring cultural variation in the definitions of psychiatric disorders. While recognizing the importance of this issue, it is suggested here that a considerable amount of ethnographic evidence indicates that many types of comparative effort can be carried out without cultural injustice. It is also urged that anthropologists provide a system for classifying cultures so as to foster an understanding of the ways in which shared beliefs and meanings can influence psychiatric illness. Categorizing populations as Western versus Non-Western or Developed versus Developing is inadequate as a basis for studying the cultural context of psychiatric illness in different parts of the world.

Led (astray) by genetic maps: the cartography of the human genome and health care

Advocates of projects to map the human genome claim that the information produced will illuminate the causes of human disease, improve treatment and, in general, increase our health and well-being. While concerns about the costs of mapping and the possible discriminatory and eugenic applications of the information it will provide have received some attention, assumptions implicit in the biomedical discourse in which its 'benefits' are proposed and which are shaping definitions of illness and health, normality and abnormality, have not yet been adequately analyzed. This paper examines how the genetic stories about mapping and its potential products being told in the biomedical (and popular) literature continue a tradition of reductionism and determinism. This new 'cartography', by adopting the blueprint as a metaphor for genes, leads to restricted conceptions of health and illness, reinforces inequities in the distribution of health and, by privatizing and individualizing responsibility for health, creates and legitimizes a new arena for social control.